08 Aug Common Combined Restrictive and Malabsorptive Procedures

There are three types of weight loss surgery. 1. Restrictive procedures 2. Malabsorptive procedures and 3. Combined Restrictive and Malabsorptive procedures. The common examples of restrictive procedures, the Adjustable Gastric Band and the Gastric Sleeve, were already discussed in a previous entry. The Jejunoilieal Bypass is a malabsorptive procedure but surgeons no longer perform this procedure. There really are no malabsorptive procedures popular today. For this discussion, I will focus on the examples of combined restrictive and malabsorptive procedures.

The most popular combined procedure performed today is the Roux-en-Y gastric Bypass (pronounced roo-en-why). Other combined procedures that are less popular but certainly worth discussing include the Biliopancreatic Diversion with Duodenal Switch and the Mini-Gastric Bypass. Because of the unique and colorful background of the Mini-Gastric Bypass, this will be discussed separately.

ROUX-EN-Y GASTRIC BYPASS

The Roux-en-Y gastric bypass is considered the gold standard for the past 30 years and was introduced by Dr. Mason in 1977 to overcome the high incidence of bile reflux found in the loop bypass. Since 1993, most of the Roux-en-y gastric bypass procedures are performed laparoscopically and it remains by far the most frequently performed gastric bypass procedure today. The operation is quite technically challenging when performed laparoscopically and for this reason, anyone considering this operation should seek out a surgeon who has performed at least 100 laparoscopic Roux-en-y procedures. Although technically more difficult than the open version, the laparoscopic Roux-en-Y offers many advantages that have most surgeons choosing the laparoscopic over the open approach. The laparoscopic approach provides faster recovery time, shorter hospital stays, and less wound complications than the open procedure. Other medical problems associated with obesity are dramatically improved after the Roux-en-Y.

The operation is difficult to describe in words to a non-surgeon, but nonetheless, I’ll give you the basics. Feel free to skip to the next paragraph if you find your head starting to spin. The operation involves the division of the stomach into a small gastric pouch (usually around 15 to 30 milliliters in volume). Next, the small bowel is divided and the distal end (called the alimentary limb since it carries the food) is connected to the small stomach pouch. The proximal end of the small bowel (referred to as the biliary limb since it carries the bile and pancreatic fluids from the bypassed segment of stomach and intestine) is then connected back into the side of the small bowel. How far down this connection is made depends on whether the surgeon is performing a standard Roux-en-Y (around 75 cm downstream) or a distal Roux-en-Y (around 200 cm downstream). The common channel describes the small bowel beyond this connection, since both bile and food are passing through it.

Even though the Roux-en-Y is considered both a restrictive and malabsorptive procedure, most of the weight loss effect comes from the restrictive portion of the operation. By limiting the size of the stomach to an ounce or less, the ability to eat large quantities of food is severely limited. The size of the opening between the stomach and the small bowel is also limited, giving the operation not only a restrictive component, but also somewhat of an obstructive component so, much like sand through an hourglass, food passes through the opening between the stomach and small intestine at a limited rate.

This configuration results in substantial weight loss and resolution of comorbidities. Average weight loss after the Roux-en-Y gastric bypass is around 60 to 70% of excess weight. Obesity-related health issues are dramatically improved or even resolved after surgery.

Patients who have had a Roux-en-Y gastric bypass are at risk for vitamin and mineral deficiency and stomach ulcer formation. Careful monitoring can avoid these problems, or at least correct them before they become problematic. However, after five years, patients can expect to gain 25 to 35% of their weight back. Although revisions are possible, they are technically even more challenging than the initial operation, and will likely need to be performed by a highly experienced bariatric surgeon with special experience in revision surgery.

The Biliopancreatic Diversion with Duodenal Switch

Not only is the name long and complicated, so are the technical aspects of performing this very powerful weight loss procedure. Simply referred to as the Duodenal Switch procedure, this operation is one of the most powerful weight loss operations performed today. Patients typically lose 80% or more of their excess weight. The operation accomplishes this by creating a small stomach and then bypassing all but the last few feet of small intestine. Like its predecessors that relied primarily on the malabsorptive component for weight loss, patients who undergo the Duodenal Switch are at risk for chronic diarrhea, protein malnutrition, and vitamin and mineral deficiencies. Although it is actually one of the most powerful of the weight loss procedures, the higher level of risk associated with this procedure limit its use and popularity.

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